Background: Against medical advice (AMA) discharges are often emotionally charged for healthcare providers. Complicated capacity assessments, confusion regarding legal and ethical obligations to patients, and limited resources may strain providers. This cross-sectional survey study explored provider perceptions, experiences, and self-assessed competence with AMA discharges at a county hospital with a high AMA rate.

Methods: Surveys, designed by the authors, asked participant providers to identify their role at Hospital X, provide a self-assessment of their adherence to and knowledge of AMA discharge protocols, voice opinions on provider responsibilities in arranging follow up for patients who leave AMA, and give suggestions about the AMA process. Surveys were distributed by the authors to providers at department meetings in Internal Medicine and Surgery and nursing conferences. 178 healthcare providers completed the survey (49% nurses, 19% trainee physicians, 21% attending physicians, and 11% other providers).  Data were analyzed without identifying information. STATA statistical software was used to analyze quantitative data.  NVivo was used to perform qualitative analyses.

Results: 94% of providers agreed that they were comfortable assessing capacity, and 94% agreed that they were comfortable talking with patients about the risks of leaving AMA.  Nurses and attending physicians were more likely than trainee physicians to agree that they knew what to do if patients lacked capacity.  When talking about follow up, physicians demonstrated more agreement than nurses that patients who leave AMA should receive medications (89% vs. 64%, p=0.001) and should not lose their rights to follow up (86% vs. 63%, p=0.004), but neither group agreed that transportation should be arranged (35% vs. 36%). 34.5% of providers ranked addiction as the most common driver of AMA discharge, followed by familial obligations (19%), dissatisfaction with hospital care (16%), and financial concerns (15%).  Providers had many questions and gave numerous suggestions about all aspects of the AMA process. 

Conclusions: At the study hospital, healthcare providers overall felt competent in assessing capacity and talking with patients about the risks of AMA discharge.  Nurses and physicians differed in their thoughts on how providers should handle arranging follow up appointments and medications.  Few providers agreed that they should be responsible for arranging transportation for patients leaving AMA, though the State Hospital Association Guidelines as well as Hospital X’s policy on AMA discharges recommend arranging appropriate transportation. Models of standardized best-practice approaches for AMA discharges have been proposed by bioethicists, and translating these models to practice will require buy-in from bedside providers.  Results from this survey will be used to guide future educational and policy interventions in order to improve the safety of AMA discharges.